Provider Demographics
NPI:1396781373
Name:OVERLAKE REPRODUCTIVE HEALTH INC., PS
Entity type:Organization
Organization Name:OVERLAKE REPRODUCTIVE HEALTH INC., PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-646-4700
Mailing Address - Street 1:PO BOX 84353
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-5653
Mailing Address - Country:US
Mailing Address - Phone:425-646-4700
Mailing Address - Fax:425-646-1076
Practice Address - Street 1:1135 116TH AVE NE
Practice Address - Street 2:SUITE 640
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4623
Practice Address - Country:US
Practice Address - Phone:425-646-4700
Practice Address - Fax:425-646-1076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8128084Medicaid
WAG217117600Medicare PIN